The S-T interval was prolonged in all but 1 case (97 per cent), and varied from 0.36 to 0.60 second,

PROGNOSIS

Twenty-two patients in this study have been traced; 15 (68 per cent) died from heart disease an average of seven months after examination. In 5 instances definite information has been obtained that death occurred during the Adams-Stokes' attacks. The largest number of deaths occurred in the fifth and seventh decades, 4 and 7, respectively. Seven patients are known to be alive; 6 report improvement, and 1, no change. One patient has been under observation at the Mayo Clinic for fifteen years, and we have electrocardiographic records over a period of nine and one-half years. She is still in very good health and leading a strenuous life. She has never had Adams-Stokes' seizures.

The prognosis in cases of complete heart-block is evidently not dependent so much on the presence of the block as on the integrity of the myocardium and the occurrence of Adams-Stokes' attacks. Of the patients with Adams-Stokes' seizures, 73 per cent have died from heart disease.

CASES COMING TO NECROPSY

Case 1. (A145709). A man, aged sixtyseven years, a farmer, came to the Mayo Clinic November 13, 1915, complaining of spells of unconsciousness, shortness of breath, and swelling of the lower extremities. He denied all previous illnesses other than occasional attacks of tonsillitis and chronic rheumatism. Six months before, he had begun to have dizzy spells, often causing him to fall. At the time of

his admission, the attacks occurred several times a day, and at times caused him to be short of breath, and very recently the lower extremities had begun to swell.

Examination revealed the heart to be markedly enlarged, the cardiac dulness extending 15 cm. to the left of the median sternal line. The rate was exceedingly slow, 27 each minute, and a loud, rough, systolic murmur was heard best at the apex, transmitted to the axilla, and through to the back. There was a marked degree of sclerosis of the peripheral arteries. The systolic blood pressure varied from 172 to 178, and the diastolic on two occasions was 70. The electrocardiogram confirmed the diagnosis of complete heart-block. The eye grounds disclosed slight engorgement of the veins; urinalysis, a moderate amount of albumin and a few hyaline casts; and roentgenograms of the chest, the cardiac enlargement and slight dilatation of the aorta. The hemoglobin was 70 per cent; the erythrocytes numbered 5,040,000, and the leukocytes 8800, with no abnormalities in the differential cell count. The blood Wassermann reaction was negative. The patient died suddenly on the seventh day in the hospital in a typical Adams-Stokes' attack.

Necropsy revealed that the heart was markedly enlarged, the right heart being especially dilated, chiefly in the region of the auricular appendage. The aortic ring was markedly fibrotic with calcification extending beyond the ring and completely destroying the corresponding area of the bundle of His. There was moderate fibrosis of the aortic leaflets. The coronaries revealed moderate sclerosis. There were fatty degenerative changes in the myocardium, with marked fragmentation of the muscle bundles. The vessels were moderately sclerotic. A moderate degree of chronic diffuse nephritis was the only other noteworthy finding.

Case 2. (A242893). A woman, aged sixty-two years, was examined at the Mayo Clinic August 21, 1918. She complained of having had three attacks of unconsciousness. There had been no significant illnesses previously. During the last year she had not felt well, complain

ing of dull intermittent pain in the left upper abdomen, and shortness of breath on exertion. Two months before, she suddenly became unconscious and had a convulsion. These phenomena had been repeated twice. She also had had transient attacks of dizziness.

Examination revealed marked enlargement of the heart, regular rhythm, and a loud, blowing, systolic murmur audible at the apex. The rate was unusually slow (32 each minute). The systolic blood pressure was 240 and the diastolic 100. There were no other noteworthy findings. The urinalysis revealed a moderate amount of albumin, but no other abnormalities. The hemoglobin was 80 per cent and the leukocytes numbered 8200. The blood Wassermann reaction was negative. Roentgen

ograms of the chest showed that both sides of the heart were enlarged. The basal metabolic rate was 0 per cent. The electrocardiogram revealed complete heartblock, and also negativity of the T wave in Derivation I. The patient died suddenly on the seventh day in the hospital, in an Adams-Stokes' attack.

Necropsy revealed marked hypertrophy and dilatation of the heart, marked fibrous and calcareous changes of the aortic and mitral valves, and of the coronary arteries. The aorta likewise was very sclerotic. The myocardium revealed areas of fibrosis, fatty degenerative changes, and brown atrophy. Other findings were an old tuberculous process in the right kidney, and chronic cholecystitis with lithiasis.

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(2) ROBINSON, G. C., and Draper, G.:

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(14) STEVENS, H. W.: Some electrocardiographic studies of patients under digitalis treatment. Bost. Med. and Surg. Jour., 1916, clxxiv, 345-350. (15) WHITE, P. D., AND SATTLER, R. R.: The effect of digitalis on the normal human electrocardiogram, with especial reference to A-V conduction. Jour. Exper. Med., 1916, xxiii, 613-630.

VIKO, L. E.: Clinical observations on the digitalis-like action of squill. Jour. Amer. Med. Assoc., 1920, lxxv, 971-976.

(17) WINDLE, J. D.: Heart-block from drugs of the digitalis group. The comparative effects of digitalis, strophanthus, squill and apocynum. Heart, 1911-1912, iii, 1-12. (18) WHITE, P. D., AND VIKO, L. E.: Clinical observations on heart block. Amer. Jour. Med. Sci., 1923, clxv, 659-666.

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aorta, 3 ed. Philadelphia, Lippincott, 1918, p. 578.

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scription of a heart showing gummatous infiltration of the auriculoventricular bundle. Lancet, 1906, ii, 1429-1431.

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de

(30) ROBINSON, G. C.: Gumma of the heart from a case presenting the symptoms of Adams-Stokes disease. Bull. Ayer Clin. Lab., 1907, iv, i. (31) VAQUEZ AND ESMEIN: Maladie Stokes-Adams par lesion sclerogommeuse du faisceau de His (Herzblock). Presse méd., 1907, xv, 57. (32) HAY, J., AND MOORE, S. A.: StokesAdams disease and cardiac arrhythmia. Lancet, 1906, ii, 1271-1276. (33) OPPENHEIMER, ADELE AND OPPENHEIMER, B. S.: Three cases of Adams-Stokes syndrome with histological findings. Arch. Int. Med., 1914, xiii, 957-969.

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(43) MACCALLUM, W. G. Quoted by Hirschfelder, A. D.

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omatous) of the auriculo-ventricular bundle of His, with sudden unexpected death. Arch. Int. Med., 1914, xiii, 640-647.

(47) GerhardT, D.: Ueber

Rückbildung

des Adams-Stokes'schen Symptomkomplexes. Deutsch. Arch. f. klin. Med., 1908, xliii, 485–499.

(48) HUME, W. E.: A case of heart-block in which there was no pathological lesion of the connecting muscular system. Heart, 1913-1914, v, 149152.

(49) KrumbhaAR, E. B.: Adams-Stokes' syndrome, with complete heartblock, without destruction of the bundle of His. Arch. Int. Med., 1910, v, 583-595.

(50) OPPENHEIMER, B. S., AND WILLIAMS,

H. B.: Prolonged complete heartblock without lesion of the bundle of His and with frequent changes in the idioventricular electrical complexes. Proc. Soc. Exper. Biol. and Med., 1912-1913, x, 86-87.

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(52) Hewlett, A. W., and Barringer, P. B.: The effect of digitalis on the ventricular rate in man. Arch. Int. Med., 1910, v, 93–101. (53) LEA, E.: Complete heart-block with higher ventricular than auricular rate. Lancet, 1915, i, 1289-1292. (54) WINDLE, J. D.: Permanent heartblock. A case with an exceptionally frequent ventricular rate. Heart, 1910-1911, ii, 102-106.

(55) MUSSER, J. H., JR.: Heart block associated with high blood pressure. Arch. Int. Med., 1917, xx, 127–144. (56) WILLIUS, F. A.: Thyroid preparations in the treatment of the AdamsStokes syndrome. (In press.) (57) WILLIUS, F. A.: Observations on negativity of the final ventricular T wave of the electrocardiogram. Amer. Jour. Med. Sci., 1920, clx, 844-865.

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I'

T IS now ten years since Rosenow first published the results of his experiments in the artificial production of peptic ulcer, cholecystitis, appendicitis, and other infections, in animals, by the intravenous injection of cultures (usually of the streptococcus viridans or hemolyticus types) made from infections in the teeth and tonsils of persons suffering from similar infections in the gastrointestinal tract, and the recovery of the same organism in the infected tissues. During the past ten years much research work along the lines suggested by Rosenow has been carried out. Laboratory research, not always carried out with Rosenow's technique, has not always been confirmatory, but in many instances results have been not only confirmatory but have added many new facts for further study. Clinical research has brilliantly confirmed the original opinion that the discovery of a definite etiological relationship between focal infections and many hitherto unexplainable chronic diseases has ushered in a new era of medicine, in which we will no longer be compelled to put our trust in empiric, medicinal, palliative measures, but will be able to adopt

Read before the American Gastro

physiologic, causative treatment and put the practice of medicine on a scientific basis.

The principal theoretical objections to Rosenow's theory have been based

on

several general observations. First, blood cultures from patients with primary and secondary foci have usually shown no growth of organisms. Second, it has been pointed out that many persons with marked focal infections apparently never develop secondary foci. Third, it has been demonstrated that the removal of focal infections has frequently not resulted in cure of the secondary foci. The first of these objections has been answered by the contention that the streptococci in the primary foci are probably thrown into the circulation only intermittently, in showers, and are rapidly dissipated. We know the difficulties encountered in obtaining positive blood cultures even in cases where bacteria are constantly being fed into the circulation, as in ulcerative endocarditis, so that where only intermittent bacteremia occurs even repeated negative cultures cannot be accepted as proof that bacteria have never been present in the blood. It has also been shown that at a primary infective focus, as for instance in the

character of given strains of strepto